Utilization Management Nurse - Drive Quality Care

SIHO Insurance Services; Columbus (IN); On-site; USD 70,000 - 90,000; Full time

Job summary

SIHO Insurance Services seeks an experienced Utilization Management Nurse in Columbus, IN. This full-time, exempt RN role focuses on coordinating care, ensuring medical necessity, and aligning services with plan guidelines across episodes of care.

You will perform pre-service, concurrent, and post-service reviews, interact with members and providers, document thoroughly in the standard system, and collaborate with the Medical Director to ensure timely, compliant decisions.

Qualifications

• RN with current, unrestricted license in primary state of employment.
• UM or Health Plan experience preferred.
• Fast-paced environment with focus on efficiency and quality.
• Strong self-directed organization and prioritization.
• Sound clinical background with clinical field experience.
• Excellent verbal and written communication skills.
• Microsoft Office Experience: Outlook, Word, Excel.

Responsibilities

• Perform pre-service, concurrent, and post-service review for medical necessity using enrollee records and guidelines.
• Interact with members, providers, and care teams to complete reviews efficiently.
• Consult with the SIHO Medical Director to ensure timely medical necessity decisions.
• Document reviews in the established system ensuring data integrity and reporting metrics.
• Complete case review and elevation to determinations within contractual and CMS turnaround times.
• Assist in resolving problems and provide guidance to team members.
• Interpret and abide by organizational policies and ensure proper policy application.
• Act as a clinical resource for medical management, utilization review, and medical necessity.
• Support department strategies focused on quality improvement.
• Identify and report potential Quality of Care concerns and Fraud, Waste and Abuse incidents.
• Work as part of an interdisciplinary team for all lines of business.

Skills

RN licensure

UM/Health Plan experience

Fast-paced environment

Time management

Clinical background

Verbal & written communication

MS Office (Outlook, Word, Excel)

Tools

Outlook

Word

Excel

Job description

SIHO Insurance Services seeks an experienced Utilization Management Nurse in Columbus, IN. This full-time, exempt RN role focuses on coordinating care, ensuring medical necessity, and aligning services with plan guidelines across episodes of care.

You will perform pre-service, concurrent, and post-service reviews, interact with members and providers, document thoroughly in the standard system, and collaborate with the Medical Director to ensure timely, compliant decisions.